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New patients

    Patient Information

    Patient Name
    Gender
    Birthdate
    Civil Status
    Preferred Name
    Email
    Address
    Phone (Home)
    Phone (Work)
    Mobile
    Employer
    Occupation
    Preferred Method of Contact
    Are you of Aboriginal or Torres Straight Island Descent

    Insurance Information

    Private Health Insurance Carrier
    Membership Number
    Your Referrence No.
    Name of Medical Practitioner
    Contact Number

    How did you first hear of us?

    Dr.
    Other

    Dental History

    What is your present dental concern
    When was your last dental appointment
    Do you have dental problems now?
    If yes, please describe

    a. Health

    Are you concerned about or experiencing any of the following

    b. Function

    Are you experiencing any of the following

    c. Cosmetics/Aesthetics

    Are you dissatisfied with your teeth and appearance.
    Is there anything you would like to change about your smile
    Are you concerned particularly about any of the following

    This section is essential to us in providing safe medical treatment:

    Do you have any of the following? Please tick
    Hepatitis Type
    Other Allergy
    Other
    Are you, or could you be pregnant?
    Do you smoke?
    Are your currently taking any medications or other drugs?
    If yes, please state?
    Recall Appointments — Your recall appointment will be made at the completion of treatment
    A SMS or Phone Call will be given one week prior to this appointment. Please let our reception know if this doesn't suit.

    Terms and Conditions

    I understand the above information is necessary to provide me with dental care in a safe and efficient manner.
    I have answered all questions to the best of my knowledge. I will notify the dentist of any change in my health or medication.
    I further consent to having my photograph taken to be replaced on my personal dental file.

    Signature
    Date

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